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Sunday, May 14, 2017

Corneal Ulcer - Clinical features And Management

A corneal ulcer is an inflammatory and ulcerative keratitis.

Common infectious etiologies include

  • bacteria (Staphylococcus, Streptococcus, Pseudomonas) and 
  • viruses (herpes simplex, adenovirus). 
  • Rare causes of corneal ulcers include fungal infections and Acanthamoeba, a ubiquitous protozoan associated with contaminated contact lens solutions.

- Bacterial corneal ulcers are commonly associated with extended-wear contact lenses.
- Fungal infections may also arise from trauma involving vegetable matter such as a tree branch.  - - - -Acanthamoeba infections may also occur from swimming in lakes, especially while wearing contact lenses.

Corneal Ulcer. A small circular corneal infiltrate is seen adjacent to the white flash photography reflection. Diffuse conjunctival hyperemia with a nasal ciliary flush is seen.

Clinical Features:Patients present with pain, photophobia, decreased vision, discharge, and a foreign body sensation.
Ocular findings include a corneal infiltrate, typically a round white spot, with conjunctival hyperemia, meiosis, and chemosis.
 Slitlamp biomicroscopy may demonstrate an epithelial defect with fluorescein uptake. Anterior chamber findings can include cells and flare, keratic precipitates, and a hypopyon.


Management

  • Corneal ulcers are an ophthalmologic emergency requiring emergent ophthalmology consultation. 
  • Stains and cultures should be obtained as expeditiously as possible. 
  • Intensive topical treatment using fortified antibiotics is the most effective treatment route, initially given every 30 to 60 minutes.
  • For mild cases, a single fluoroquinolone agent may suffice.
  • For more severe cases, dual therapy using a cephalosporin or vancomycin combined with an aminoglycoside is recommended.
  • Clinical improvement is usually noted after 2 to 3 days.
  • Systemic antibiotics are used in cases where the sclera is involved (Pseudomonas) or if there is a high risk of concurrent systemic disease (Neisseria, Haemophilus). 
  • Cycloplegics are recommended if there is an accompanying iritis. 
  • Steroids and eye patching are contraindicated. 
  • A contact lens wearer must discontinue contact lens wear.

Points To Remember
1. A corneal ulcer is an ophthalmologic emergency.
2. Extended-wear contact lens use is a risk factor for corneal ulcer.
3. Pseudomonas aeruginosa, associated with thick yellow green or blue-green mucopurulent tenacious exudate, is capable of destroying the cornea within 6 to 12 hours.

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